Inspection·October 19, 2023

F 0636 Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.18.11, effective 10/01/2023, revealed the following [in part]: Level of Harm - Minimal harm or potential for actual harm CH 2: Assessments for the RAI Residents Affected - Few Comprehensive Assessments Assessment Management Requirements and Tips for admission Assessments: Since a day begins at 12:00 a.m. and ends at 11:59 p.m., the actual date of admission, regardless of whether admission occurs at 12:00 a.m. or 11:59 p.m., is considered day 1 of admission. The ARD (item A2300) must be set no later than day 14, counting the date of admission as day 1. Since a day begins at 12:00 a.m. and ends at 11:59 p.m., the ARD must also cover this time period. For example, if a resident is admitted at 8:30 a.m. on Wednesday (day 1), a completed RAI is required by the end of the day Tuesday (day 14). Federal statute and regulations require that residents are assessed promptly upon admission (but no later than day 14) and the results are used in planning and providing appropriate care to attain or maintain the highest practicable well-being. This means it is imperative for nursing homes to assess a resident upon the individual's admission. The IDT may choose to start and complete the admission comprehensive assessment at any time prior to the end of day 14. Nursing homes may find early completion of the MDS and CAA(s) beneficial to providing appropriate care, particularly for individuals with short lengths of stay when the assessment and care planning process is often accelerated. The MDS completion date (item Z0500B) must be no later than day 14. This date may be earlier than or the same as the CAA(s) completion date, but not later than. The CAA(s) completion date (item V0200B2) must be no later than day 14. The care plan completion date (item V0200C2) must be no later than 7 calendar days after the CAA(s) completion date (item V0200B2) (CAA(s) completion date + 7 calendar (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 2 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0636 days). Level of Harm - Minimal harm or potential for actual harm If a resident had an OBRA admission assessment completed and then goes to the hospital (discharge return anticipated and returns within 30 days) and returns during an Residents Affected - Few assessment period and most of the assessment was completed prior to the hospitalization, then the nursing home may wish to continue with the original assessment, provided the resident does not meet the criteria for an SCSA. In this case, the ARD remains the same and the assessment must be completed by the completion dates required of the assessment type based on the time frame in which the assessment was started. Otherwise, the assessment should be reinitiated with a new ARD and completed within 14 days after reentry from the hospital. The portion of the resident's assessment that was previously completed should be stored on the resident's record with a notation that the assessment was reinitiated because the resident was hospitalized . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 3 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a summary of the baseline care plan was provided to the resident and their representative for 5 of 12 residents (Resident #s 163, 165, 170, 173, and 182) reviewed for baseline care plans following admission into the facility for skilled nursing care services, in that: 1. Resident #163's baseline care plan was dated 10/16/23 and a summary had not been provided to her. 2. Resident #165's baseline care plan was dated 8/23/23 and a summary had not been provided to him. 3. Resident #170's baseline care plan was dated 10/13/23 and a summary had not been provided to him. 4. Resident #173's baseline care plan was dated 9/20/23 and a summary had not been provided to him or his representative. 5. Resident #182's baseline care plan was dated 10/13/23 and a summary had not been provided to her. The facility's failure placed the residents at risk for not receiving information regarding the care and services to be provided to meet their needs and to promote their physical and mental health and well-being within their new living environment. The findings included: 1. Resident #163 Review of Resident #163's admission Record, dated 10/19/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: chronic pain syndrome; malignant neoplasm of female breast (breast cancer); type 2 diabetes mellitus; anxiety disorder; depression; post-traumatic stress disorder; hypertension (high blood pressure); and fracture of neck of left femur (left hip fracture). Review of Resident #163's care plans revealed a baseline care plan dated 10/16/23. Review of the progress notes, dated 10/14/23 through 10/19/23, revealed no documented evidence a summary of the baseline care plan was provided to Resident #163. In an interview on 10/19/23 at 9:30 AM, Resident #163 stated she had not had her baseline care plan reviewed with her and had not been provided with a copy of it. She stated she was supposed to have a meeting with the staff on Monday (10/23/23). 2. Resident #170 Review of Resident #170's admission Record, dated 10/19/23, revealed a [AGE] year-old male admitted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 4 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Level of Harm - Minimal harm or potential for actual harm to the facility on [DATE] with diagnoses including: gangrene; type 2 diabetes mellitus; depression; paraplegia (partial paralysis in lower extremities); hypertension (high blood pressure); and colostomy status (surgical procedure that creates an opening into the large intestine and provides an alternate channel for feces to leave the body and empty into a bag). Residents Affected - Some Review of Resident #170's care plans revealed a baseline care plan dated 10/13/23. Review of the progress notes, dated 10/12/23 through 10/19/23, revealed no documented evidence a summary of the baseline care plan was provided to Resident #170 and/or the resident's representative. In an interview on 10/17/23 at 2:50 PM, Resident #170 stated the staff had not provided a summary of his baseline care plan to him, but he thought his family member may have attended a meeting to discuss his care. 3. Resident #173 Review of Resident #173's admission Record, dated 10/19/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] following a temporary hospitalization. The resident's diagnoses included: fracture of the neck of the right femur (broken right hip); chronic obstructive pulmonary disease (lung disease that affects breathing and causes shortness of breath); and malignant neoplasm of bronchus (lung cancer). Review of Resident #173's care plans revealed a baseline care plan dated 8/23/23. Review of the progress notes, dated 8/23/23 through 10/19/23, revealed no documented evidence a summary of the baseline care plan was provided to Resident #173 and/or the resident's representative. 4. Resident #165 Review of Resident #165's admission Record, dated 10/18/23, revealed an [AGE] year-old male initially admitted to the facility on [DATE] and a return date on 10/03/23. The resident's diagnoses included: heart failure; anemia; hypothyroidism (low thyroid hormone level); hyperlipidemia (high cholesterol level); depression; essential hypertension (high blood pressure); hyperglycemia (high blood sugar level); end stage renal disease (advanced stage of kidney failure and loss of kidney function); and dependence on renal dialysis. Review of Resident #182's care plans revealed a baseline care plan dated 9/20/23. Review of the progress notes, dated 9/19/23 through 10/19/23, revealed no documented evidence a summary of the baseline care plan was provided to Resident #165. 5. Resident #182 Review of Resident #182's admission Record, dated 10/18/23, revealed an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of fracture of shaft of humerus, left arm (broken upper left arm). Review of Resident #182's care plans revealed a baseline care plan dated 10/13/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 5 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Level of Harm - Minimal harm or potential for actual harm Review of the progress notes, dated 10/13/23 through 10/19/23, revealed no documented evidence a summary of the baseline care plan was provided to Resident #182. In an interview on 10/17/23 at 11:25 AM, Resident #182 stated no one had provided a summary of the baseline care plan to her the day or two following her admission into the facility. Residents Affected - Some In an interview on 10/18/23 at 2:53 PM, LVN MDS Coordinator C stated she did residents' baseline care plans. She stated she did not review the baseline care plan with the residents and/or representatives. LVN C stated when the charge nurse completed the Nursing admission Assessment, the nurse was supposed to review the assessment and the resident's list of medications with the resident and/or representative. LVN C did not know who reviewed the baseline care plans with the residents or if a copy of the baseline care plan was provided to the residents and/or representatives. In an interview on 10/18/23 at 2:56 PM, the Corporate MDS Coordinator stated the facility MDS Coordinators were responsible for putting the baseline care plans in the system, but they did not review the baseline care plans with the residents and/or representatives. In an interview on 10/18/23 at 10:16 AM, the RN Corporate Director of Clinical Services stated the Nursing admission Assessment was completed by the admitting charge nurse. She stated the baseline care plan was developed from the Nursing admission Assessment. The RN Corporate Director of Clinical Services stated the Nursing admission Assessment was reviewed the next business day with the resident and/or representative. Review of the facility policy and procedure for Comprehensive Person-Centered Resident Care Planning, not dated, revealed the following [in part]: The facility will develop and implement a baseline care plan for each resident that includes instructions need to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will: (i) be developed within 48 hours of a resident's admission . The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive assessment is developed within 48 hours of the resident's admission and meets all requirements of a comprehensive care plan. The facility will provide the resident and resident representative with a summary of the baseline care plan that includes but is not limited to: (i) the initial goals of the resident; (ii) a summary of the resident's medications and dietary instructions; (iii) any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and (iv) any updated information based on the details of the comprehensive care plan, as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 6 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objective and time frames to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 18 residents (Resident #173) whose care plans were reviewed, in that: Resident #173 had an order to use supplemental oxygen continuously. The resident's comprehensive care plan did not address the resident's use of oxygen and the care needs associated with the use of supplemental oxygen. This failure placed the resident at risk for not receiving supplemental oxygen therapy as ordered and needed. The findings included: Review of Resident #173's admission Record, dated 10/19/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] following a temporary hospitalization. The resident's diagnoses included: fracture of the neck of the right femur (broken right hip); chronic obstructive pulmonary disease (lung disease that affects breathing and causes shortness of breath); and malignant neoplasm of bronchus (lung cancer). Review of Resident #173's Order Summary revealed an order dated 8/31/23 for oxygen at 2 liters per minute vial nasal cannula continuously. Check oxygen saturation every shift and keep oxygen saturation at or greater than 92%. Record oxygen saturations every shift. Review of Resident #173's comprehensive MDS Assessment, dated 9/04/23, revealed the resident was assessed as receiving oxygen therapy while in the facility. Review of Resident #173's baseline care plan, dated 8/23/23, revealed it did not include a care plan for oxygen use. The care plan had not been updated to address the use of continuous oxygen therapy to maintain blood oxygen saturation. Observation on 10/16/23 at 12:21 PM revealed Resident #173 was lying on his right side in bed with the head of the bed elevated. The resident's oxygen nasal cannula was lying on the side of the mattress and was not being used by the resident. In an interview on 10/18/23 at 2:56 PM, the Corporate MDS Coordinator stated LVN E had been the MDS Coordinator for the skilled care residents and had been responsible for completing the MDS assessments and care plans for the residents receiving skilled care. The Corporate MDS Coordinator stated LVN E's last day on duty had been 10/11/23 and she no longer worked in the facility. Review of the facility policy and procedure for Comprehensive Person-Centered Resident Care Planning, not dated, revealed the following [in part]: Each resident's plan of care shall be periodically reviewed and revised by an interdisciplinary team after each MDS assessment, including both the comprehensive and quarterly review assessments to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 7 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 reflect the resident's current care needs . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 8 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop the comprehensive care plan with the participation of the resident and the IDT for 2 of 12 residents (Residents #46 and #55) reviewed for care plans, in that: 1. Resident #46 was not invited to participate in her care plan conference. 2. Resident #55 was not invited to participate in her care plan conference. This facility failure placed the residents at risk for individual needs not being identified and addressed and decreased feelings of self-determination and psychosocial well-being within their living environment. The findings included: 1. Resident #46 Record review of Resident #46's face sheet, dated 10/18/2023, revealed resident was a [AGE] year-old female, admitted to the facility on [DATE]. She had a primary diagnosis of unspecified dementia (mild memory disturbance due to a known physiological condition). Record review of Resident #46's Significant Change MDS dated [DATE] revealed Resident #46's BIMs score was 99 , (which is a score that reflects cognitive function), the staff assessment revealed moderately impaired (decisions poor; cues/supervision required). In an interview on 10/17/23 at 11:31 AM, Resident #46 stated she could not remember the last care plan meeting she was included in or attended. She revealed that she had some things she would like to discuss concerning her care, but she had not had a care plan meeting this year that she had been invited to attend. Record review of Resident #46's electronic record revealed there was a Care Plan Review completed on 02/10/2023, but it did not include the IDT, such as an RN, Resident #46 or the resident's representative; it was only completed by the MDS Coordinator who was an LVN. Record review of the Care Conference Schedule and EMAR revealed that there was not a Care Conference or IDT meeting scheduled after the Significant Change MDS was completed or after the Care Plan was completed. In an interview on 10/18/23 on 03:30 PM, the MDS Coordinator revealed that Resident #46 had a Significant Change assessment, but she did not have an IDT meeting, or a care conference completed with it. She revealed that it was a mistake and that it should have been completed. She revealed that EMAR documentation reflected that they did not complete an IDT after her SC assessment. She revealed that it had not been completed and that the failure placed the resident at risk of not capturing the care area and care needs. 2. Resident #55 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 9 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #55's face sheet, dated 10/18/2023, revealed the resident was a [AGE] year-old female, admitted to the facility on [DATE]. She had a primary diagnosis of bipolar disorder . Record review of Resident #55's MDS assessment dates revealed there was an admission MDS, dated [DATE], with the last Quarterly MDS, dated [DATE]. There were several Entry MDS assessments, Quarterly MDS assessments and Discharge Return Anticipated MDS assessments during the time from admission to current, 10/18/2023. Resident #55's last BIMs score was 8 (cognition was moderately impaired). In an interview on 10/16/23 at 9:53 AM, Resident #55 stated she had never been invited or attended a care plan conference meeting. Record review in Resident #55's electronic record revealed there was a Care Plan Conference report, dated 05/11/2023, but when the document was opened or viewed, it was blank with a note that reflected the resident was in the hospital. There was no other Care Plan Conference Reports in Resident #55's electronic record from the time of admission to 10/18/2023. In an interview on 10/18/23 at 1:29 PM, the MDS Coordinator said the Social Worker was responsible for scheduling the IDT Care Plan Meetings. She looked in Resident #55's electronic record and there was not any documentation of a care plan meeting from the time of admission to present, 10/18/2023. She revealed that it had not been done. In an interview on 10/18/23 at 1:39 PM, the Social Worker said she was responsible for scheduling residents for their IDT Care Plan Meetings. She said Resident #55 was in the hospital when she was scheduled for her IDT Care Plan Meeting. The Social Worker reviewed Resident #55's electronic record and said she had not had an IDT Care Plan Meeting since admission. She also said Resident #55 should have had one last August 2023 but didn't. She said the failure was due to the resident going in and out of the facility frequently and the system did not flag/notify her Resident #55 should have had one. She said the DON asked her to clear off her flags/notifications off the system and as a result she missed it. In an interview on 10/18/23 at 3:02 PM, the DON stated she did ask the Social Worker to clear her flags/notification for Resident #55 due to the resident going in and out the facility frequently, but she should keep a record or keep track of it. The DON said Resident #55 had gone to the hospital 4 times since admission and as a result her IDT Care Plan Meeting was probably missed. She said a potential outcome of the failure would be a resident need would not be identified or met. Record review of the facility policy Resident Assessment, not dated, revealed the following [in part]: It is the policy of this facility to conduct and document, initially and periodically, a comprehensive, accurate, standardized, reproducible assessment of a resident's functional capacity on all residents admitted to the facility. Comprehensive Person-Centered Resident Care Planning: A comprehensive person-centered care plan is developed and implemented for each resident, consistent with the resident's rights and will incorporate resident-centered goals and wishes about their care, activities, and lifestyle to include measurable short-term and long-term objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 10 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 the comprehensive assessment. Level of Harm - Minimal harm or potential for actual harm Each resident's comprehensive care plan shall be developed within seven days after completion of the comprehensive assessment. Comprehensive care plans are prepared by an interdisciplinary team. Residents Affected - Some Each resident's plan of care shall be periodically reviewed and revised by an interdisciplinary team after each MDS assessment, including both the comprehensive and quarterly review assessments to reflect the resident's current care needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 11 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure discontinued medications were secured in 1 of 1 medication rooms reviewed for pharmacy services. ADON A failed to ensure that medications that had been discontinued were secure. This failure could place the residents who resided in the facility at risk of a drug diversion. The findings included: During an observation from surveyors of the office on [DATE] at 3:15 PM, revealed ADON A's office door was unlocked, opened and unattended. Under her desk were 2 large boxes and 1 small box that contained various discontinued and expired prescription medications. The medications were located on the floor under her desk. During an interview on [DATE] at 3:30 PM, ADON A revealed that the medications were not stored accurately and that all medications once discontinued should be secured from un-licensed employees and residents. She said that she had received training and she knew that all medications should not be left unattended if they were not locked up. She revealed she had pulled the medications to discard of them, placed them under her desk and then forgot to close her office door when she left. She revealed that the failure could place residents at risk if they gained access to medications that were not theirs, and/or medication issues if unauthorized employees were to obtain them. During an interview on [DATE] at 3:45 PM, the DON revealed that her expectations are for all medications to always locked up. She revealed that the medications under the ADON A desk were discontinued medications and that they should not have been left in an office with the door open. She revealed that this failure could cause unauthorized personnel to gain access to the medications. She revealed that she was completing in-service on proper storage of medications. Review of printed TAC policy that was used as the facility policy, dated on [DATE], titled, Texas Administrative Code states, revealed (g) Mediations of deceased residents, medications that have passed the expiration date, and medications that have been discontinued must be securely stored and reconciled. These medications must be disposed of according to federal and state laws or rules on a quarterly basis. Discontinued drugs may be reinstated if reordered prior to destruction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 12 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure dietary service personnel wore hair coverings in 1 of 1 kitchen reviewed for kitchen sanitation, in that: Residents Affected - Some Dietary Aide F did not wear an appropriate hair restraint to cover his mustache while working in the kitchen. This failure placed the residents at risk for food borne illness and consumption of contaminated food. The findings included: In an observation and interview on 10/15/2023 10:30 AM, during the initial tour of kitchen, revealed Dietary Aide F was preparing food and his mustache was uncovered by the beard/hair restraint. His mustache covered his upper lip and was longer than stubble (1/4 inch and ½ inch in length). The Dietary Manager said Dietary Aide F's mustache should have been covered and she would have him cover it. Observation on 10/15/2023 at 09:15 AM, in the main dining room dish washing area revealed Dietary Aide-F was washing dishes and not wearing a beard restraint to cover his beard which was approx. 1 ½ to 2 inches in length. Observation on 10/15/2023 at 11:40 AM, in the kitchen revealed Dietary Aide F plated food for residents and wore a beard restraint, however it did not cover his mustache and left his upper lip exposed. In an interview on 10/15/2023 at 11:40 AM, Dietary Aide F stated, the facility allowed staff to wear beards as long as they were covered in the kitchen . In an interview on 10/15/2023 at 11:45 AM, the Dietary Service Manager stated, It's been a long time since a male has worked in the kitchen, but they are allowed to have beards and mustaches; however, they must be covered when in the kitchen. The DSM further stated, A negative resident outcome on finding hair in the resident's food might be a loss of trust in the kitchen and a dislike of the food the hair was found in. In an interview on 10/15/2023 at 11:55 AM, the Administrator stated, It's our policy that all hair is to be covered while in the kitchen and I expect company policy to be followed. Record review of a facility policy titled Nutrition Services Personnel Hygiene, dated January 1, 2010, revealed [in part]: 1. Nutrition Services personnel must meet acceptable standards of personal hygiene, appearance, and behavior. C. Hair clean and worn in a manner that can be completely covered by hair restraint. Hair nets or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 13 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676415 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 other hair restraint to be worn by employees at all times in the kitchen. Level of Harm - Minimal harm or potential for actual harm The Food and Drug Administration Food Code 2022 specified [in part]: Chapter 2 Management and Personnel Residents Affected - Some Part 2-4 Hygienic Practices Section 2-402 Hair Restraints 2-402.11 Effectiveness A. Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676415 If continuation sheet Page 14 of 14